A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?
Ask an experienced nurse to assist with the procedure.
Refuse to take the assignment.
Identify that the task is in the scope of RN practice and perform the suctioning.
Delegate the task to assistive personnel.
The Correct Answer is A
Choice A reason: Asking an experienced nurse to assist ensures the procedure is performed safely while allowing the newly licensed nurse to gain competence. Tracheal suctioning requires sterile technique and skill to avoid complications like hypoxia or trauma. This approach supports patient safety and professional development, aligning with nursing standards.
Choice B reason: Refusing the assignment is inappropriate, as tracheal suctioning is within an RN’s scope of practice. Refusal avoids responsibility without addressing the client’s needs or the nurse’s professional growth. Seeking assistance ensures safe care while building skills, making this choice less effective and unprofessional.
Choice C reason: Performing tracheal suctioning without prior experience risks patient harm, as it requires precise technique to prevent complications like mucosal damage or infection. Without guidance, errors are more likely. Seeking supervision ensures safety and competence, making this choice unsafe and inappropriate for a novice nurse.
Choice D reason: Delegating tracheal suctioning to assistive personnel is inappropriate, as it is a sterile procedure requiring RN-level skills and judgment. Assistive personnel are not trained for invasive procedures like suctioning, which risks complications. This choice violates delegation principles and compromises patient safety, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Hypothermia increases metabolic demand in newborns, depleting glucose stores rapidly. Neonates have limited glycogen reserves, and cold stress accelerates glucose use for thermogenesis, risking hypoglycemia. This is critical in nurseries, as thermoregulation is essential to prevent metabolic imbalances in vulnerable infants.
Choice B reason: Thrombocytopenia, low platelet count, affects clotting, not glucose metabolism. It may occur in sepsis but does not directly cause hypoglycemia. Glucose regulation depends on liver function and insulin balance, not platelets, making this irrelevant to hypoglycemia risk in newborns.
Choice C reason: Prematurity heightens hypoglycemia risk due to immature liver glycogen stores and limited gluconeogenesis. Preterm infants have high metabolic demands and low reserves, increasing susceptibility to low blood glucose, necessitating close monitoring and early feeding to stabilize glucose levels.
Choice D reason: Anemia, low red blood cell count, impacts oxygen delivery but not glucose metabolism directly. Severe anemia may increase metabolic stress, but it is not a primary hypoglycemia cause. Glucose regulation relies on hepatic and insulin functions, not hematologic status, in newborns.
Choice E reason: Maternal diabetes causes fetal hyperinsulinemia from maternal hyperglycemia, leading to neonatal hypoglycemia post-birth. Excess insulin depletes glucose stores after umbilical cord clamping, as maternal glucose supply ceases, making this a critical risk factor requiring vigilant monitoring in newborns.
Correct Answer is A
Explanation
Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.
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